HEALTH HISTORY / DENTAL

Patients First Name Male Female

GENERAL HEALTH QUESTIONS 1. Have you had any serious illness, operations or hospitalizations? Yes No _______________________________________________________________________________________________________________ 2. Are you under a physicians care at this time? Yes No Name, address and phone # of physician: __________________________________________________ ___________________________________________________________ Do you have or did you ever have any of the following? Cardiovascular Health/ Muscular-Skeletal/CNS/Mental Health 3. High blood pressure Yes No 22. Joint replacement Yes No 4. Heart disease, problem or treatment Yes No 23. Arthritis Yes No 5. Rheumatic fever Yes No 24. Osteoporosis Yes No 6. Past use of Fen-Phen Yes No 25. Fainting spells or dizziness Yes No 7. Difficulty breathing when lying down Yes No 26. Seizures Yes No 8. Low blood pressure Yes No 27. Multiple sclerosis Yes No Respiratory Health 28. Anxiety/Nervousness Yes No 9. Asthma Yes No Gastro-Intestinal/Genito-Urinary Health 10.Chronic sinus problems Yes No 29. Hepatitis (A, B, C or other) Yes No Endocrine/ Blood /Immune Health 30. Kidney disease/dialysis Yes No 11. Diabetes Yes No 31. Stomach trouble/ulcers Yes No 12. Frequent thirst or frequent urination Yes No Medication Allergies and Other Allergies 13. Thyroid problems Yes No 32. Penicillin or other antibiotics Yes No 14. Abnormal bleeding, bruise easily Yes No 33. Sulfa drugs Yes No 15. Hemophilia Yes No 34. Dental anthesthetic Yes No 16. Anemia/blood disease Yes No 35. Aspirin Yes No 17. Cancer Yes No 36. Codeine/narcotics Yes No 18. Radiation therapy/chemotherapy Yes No 37.Iodine Yes No 19. HIV infections/AIDS Yes No 38. Latex products Yes No 20. Organ transplant Yes No 39. Metals/nickels/jewelry Yes No 21. Blood transfusion Yes No 40. Other: Yes No _____________________________________ Females Only 41. Are you pregnant? Yes No 42. Are you nursing now? Yes No 43. Do you take birth control pills? Yes No Medications 60. Are you taking any prescription medications, over the counter medications or herbal medicines? Yes No If so, please list them and the dose taken: ______________________________________________________________________________________________________________ 61. Do you or have you used bisphosphonate medication (Fosomax, Actonel, Boniva, Skelid, Didronel, Aredia, Zometa, Bonefos)? Yes No

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Social 62. Do you use tobacco? Yes No Quantity ____________ Per Day 63. Do you use alcohol? Yes No Quantity _____________ Per Day Per Week 64. Do you use recreational drugs? Yes No Quantity ____________ Per Day 65. Do you have any other medical conditions not listed above? Please list: ___________________________________________________________________________________________________________ I hereby certify that I have read the foregoing and filled out this questionnaire completely. I have advised you of all medical problems of which I am aware. I further certify that I, the undersigned, consent to the performing of x-rays and examination.

Signature of PATIENT or GUARDIAN ________________________ Signature of DENTIST __________________________ ID # ____________

completed this form? Yes No

Date __________ Date __________

UPDATE Have there been any changes in your medical history, including any medications that you take, since you last
Signature of PATIENT or GUARDIAN ____________________________ Date ____________ Signature of DENTIST ________________________ Date ___________

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